Form 04-828 - Games Of Chance And Contests Of Skill Permittee Quarterly Report - 1998
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1
2State of Alaska
Alaska Department of Revenue
Income and Excise Audit Division
Games of Chance and Contests of Skill
PO Box 110420
Juneau, Alaska 99811-0420
1998 Permittee Quarterly Report
Telephone (907) 465-2320
AS 05.15.080(a)
Fax (907) 465-3098
Federal EIN
Permit Number
Organization Name
Telephone Number
Mailing Address
Fax Number
City
State
Zip Code
E-mail Address
Report period (check one)
January - March
April - June
July - September
October - December
Due Date:
May 15
August 14
November 16
February 15
Types of activity (check all applicable)
Bingo
Pull-Tabs
Raffles
Contests of Skill
Dog Musher's Contest
Fish Derbies
Other - specify_____________________________
ACTIVITIES CONDUCTED BY OPERATOR OR MULTIPLE-BENEFICIARY PERMITTEE (MBP)
Enter amounts from Schedule A of the Operator or MBP Quarterly Reports
1.
Gross receipts from all games (Column A, line 10)……………………………………………………………… 1
2.
Taxes reported from all games (Column B, line 10)……………………………………………………………… 2
3.
Prizes reported for all games (Column C, line 10)…………………………………………………………………3
4.
Adjusted gross income from all games (Column D, line 10)……………………………………………………… 4
5.
Game-related expenses from all games (Column E, line 10)…………………………………………………… 5
6.
Net proceeds from all games (Column F, line 10)…………………………………………………………………6
ACTIVITIES CONDUCTED BY PERMITTEE AND VENDOR
7.
Gross receipts from all permittee and vendor activity…………………………………………………………… 7
8.
Prizes awarded from all permittee and vendor activity (including cash, merchandise, services, etc.)……… 8
9.
Adjusted gross income from all permittee and vendor activity……………………………………………………9
10. Game-related expenses from all permittee and vendor activity………………………………………………… 10
11. Net proceeds from all permittee and vendor activity………………………………………………………………11
12. Total net proceeds from permittee, vendor, operator and MBP activity (line 6 plus line 11)…………………12
We declare under penalty of unsworn falsification, that we have examined this report, including accompanying schedules and statements, and to the best of
our knowledge and belief, it is true and complete.
Member in Charge Signature
Printed Name
Date
X
President or Treasurer Signature
Printed Name
Date
X
Paid Preparer's Signature
Printed Name
Date
X
Firm Name
Firm Address
DEPARTMENT USE ONLY
PMD:
Attach a Schedule D Pull-Tab Attachment, for closed games.
Form 04-828 (Revised 11/97)
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